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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Child maltreatment

Actions to take:

Interview the child separately from the parents

Ask a parent, away from the child

Parameters to monitor:

Signs of fear or apprehension from the child when either parent is present

Negative comments about child from either parent.

Rationale:

Potential Condition: Child Maltreatment

The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.

Actions to Take

Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.

Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.

Parameters to Monitor

Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.

Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.

Potential Diagnoses: Incorrect Choices

Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.

Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.

Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A low-fat diet is inappropriate for children with cystic fibrosis; they require a high-fat, high-calorie diet.

B. Pancreatic enzymes must be taken with every meal and snack to help with nutrient absorption in children with cystic fibrosis.

C. Limiting fluid intake is not appropriate for children with cystic fibrosis; adequate hydration is important.

D. Salt intake should be increased, not restricted, in children with cystic fibrosis due to excessive salt loss in sweat.

A. Encopresis B. Pyloric stenosis C. Hirschsprung's disease D. Enterocolitis

Correct Answer is C

Explanation

A. Encopresis refers to the inappropriate passage of stool, typically seen in children with chronic constipation. It is not associated with mechanical obstruction.

B. Pyloric stenosis involves a narrowing of the pyloric sphincter, leading to projectile vomiting rather than a mechanical obstruction of the intestines.

C. Hirschsprung's disease involves inadequate motility of part of the colon due to a lack of ganglion cells, leading to a mechanical obstruction.

D. Enterocolitis refers to inflammation of the intestines and is not a primary cause of mechanical obstruction.

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?

Correct Answer is C

Explanation

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing Evaluation?

Which intervention would the nurse include when providing atraumatic care?

The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is being discharged with a cast. Which instruction would be included in the teaching?

A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?

A nurse is educating caregivers about dietary management for a child who has burn injuries. Which of the following recommendations should the nurse provide?

A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

A nurse is assessing the pain level of a 3-year old toddler. Which of the following pain assessment scales should the nurse use?